JustCare

Tag: Denial

  • UnitedHealth renames company responsible for massive inappropriate denials

    UnitedHealth renames company responsible for massive inappropriate denials

    A while back, I reported on a story in Stat News that exposed a division of UnitedHealth, NaviHealth that uses artificial intelligence, AI, to deny thousands of Medicare Advantage claims, in seconds. Now, Stat News reports that UnitedHealth is renaming NaviHealth, with all the evidence pointing towards UnitedHealth continuing to deny claims en masse with the help of the renamed company. If you need a reason not to enroll in a Medicare Advantage plan or to disenroll from one, NaviHealth or whatever it’s new name, is as good as any.

    The original Stat News story explained that UnitedHealth, as well as many other health insurance companies, rely on NaviHealth, an AI system, in its medical decisionmaking to inappropriately deny care to people in Medicare Advantage plans. Former employees at NaviHealth report that its AI algorithms wrongly deny care to Medicare Advantage enrollees in serious health.

    Employees at NaviHealth complained in internal communications that insurers were denying care to people who are on IVs in rehab facilities. Medicare should cover up to 100 days in a rehab facility or nursing home for eligible individuals. But, NaviHealth sometimes determines that people need to leave rehab before their treating physicians believe that it is appropriate for them to do so. In 2022, the Office of the Inspector General of the Department of Health and Human Services reported widespread and persistent delays and denials of care in some Medicare Advantage plans, including denials of rehab and skilled nursing services.

    As Stat previously reported, insurance corporations use AI–computer programs–to deny care to Medicare Advantage enrollees with serious diseases and injuries, when traditional Medicare would have covered the care. The NaviHealth system wrongly does not consider individual patient’s needs in its determinations about when to stop covering care. Patients, physicians and NaviHealth workers are “increasingly distressed” that patients are not able to get the care they need as a result of these computer algorithms.

    Here’s more from Just Care:

  • How big insurers please Wall Street’s investors

    How big insurers please Wall Street’s investors

    The big for-profit insurers made more than $40 billion in profits during the first six months of this year but Wall Street doesn’t consider that nearly enough. Investors have been shifting money away from those companies, which, I can assure you, has set off alarm bells in the C-Suite.

    Because top executives’ compensation is tied to meeting specific financial metrics, including shareholders’ return on investment, the CEOs are especially motivated to right the ship and reduce the percentage of revenues their companies pay out in claims to provider groups and facilities the companies don’t own. You can be certain they’ll be pulling all the levers they can think of.

    I would be surprised if some of them haven’t already called in McKinsey & Co. or another big consulting firm to look under the hood. (When I worked in the industry, the chief financial officer of one of my employers had McKinsey on a $50,000-a-month retainer.) But with the stock price falling at all of the companies while the Dow and other Wall Street indices are humming along, the consultants will be called in for a special assignment beyond any retainer. They’ll do a deep dive into the companies’ operating and staff divisions and develop recommendations to “streamline” operations, cut expenses and reallocate resources.

    Here are some things to expect in the coming weeks and months at these companies:

    Increased hardball with hospital systems: As I’ve reported, Elevance/Anthem, which owns several for-profit Blue Cross plans around the country, is in a protracted dispute with Bon Secours Mercy Health, a hospital system in Ohio and Virginia, over Medicaid and Medicare Advantage reimbursements. Earlier this month, BSMH sued Elevance/Anthem for $93 million in unpaid and disputed claims. The suit claims that Elevance/Anthem’s audits are a “bad faith attempt to bludgeon BSMH Virginia into submission in the contract negotiations, as opposed to a good faith exercise of Anthem’s discretion.”

    The dispute between the two parties has attracted considerable media attention, but there are many others across the country. Modern Healthcare reports that so far this year, 49 provider-payer contracting disputes have become public, compared to only 20 through August 2022. 

    Modern Healthcare is also reporting that many rural hospitals, which typically operate on thin margins, are considering withdrawing from Medicare Advantage networks operated by big insurers because their payments are increasingly inadequate.

    Take it or leave it pay cuts to doctors: Just as the pandemic was reaching the United States in early 2020, UnitedHealth Group sent letters to numerous physician groups demanding pay cuts of up to 60%. If the doctors — many of whom were on the front lines trying to keep Covid patients alive — refused, they’d be kicked out of UnitedHealth’s provider network. UnitedHealth rescinded or postponed some of those planned cuts temporarily, but physicians should expect to see those demands again from big insurers.

    Layoffs: I know from personal experience that when McKinsey shows up, layoffs are almost always inevitable. Job security for many employees goes out the window. I had to lay off members of my own staff over the years because of the “restructurings” and downsizing McKinsey recommended.

    Sure enough, late last month, CVS/Aetna told regulators in eight states that it would eliminate about 5,000 position — even as the company made additional acquisitions, including paying $8 billion for Signify Health, a nationwide network of 10,000 clinicians, and $10 billion for Oak Street Health, a primary care company.

    Divestitures: Speaking of CVS/Aetna, I’ve seen reports that investors are questioning the company’s “transformation” efforts, especially in light of the fact that the company’s shares have been down more than 25% since the first of the year. When Wall Street financial analysts signal dissatisfaction with the performance of a company’s operating divisions, the CEO and other executives will assess which operations have become a drain on earnings or are not working synergistically with other and more profitable divisions.

    Big insurers are like chameleons, constantly recasting themselves based on Wall Street’s whims. When I joined Cigna in 1993, the company was a large multi-line insurer with a property and casualty division, an individual insurance business, a reinsurance division and a financial services company. Aetna had similar lines of business back then. Both companies shed those operations at the behest of investors and analysts to focus exclusively on health care.

    Exiting some Obamacare markets: When the Affordable Care Act marketplaces became active in 2014, most insurers rushed in, and many, the big ones in particular, quickly rushed out. They couldn’t make enough money fast enough to satisfy Wall Street. Since then, the government has increased subsidies (at least temporarily) to help people afford their premiums and out-of-pocket obligations, and many insurers, smelling higher profits, have returned. However, this marketplace can be volatile. Cigna announced last month it is exiting some of the Obamacare markets it had recently entered.

    Redoubled efforts to enroll more seniors into Medicare Advantage: Insurers have learned that the federal government is a much more generous customer than the nation’s employers, who once were the primary source of insurers’ revenues and profits. When looking at 2021 data, Kaiser Family Foundation researchers found that “Medicare Advantage insurers reported gross margins averaging $1,730 per enrollee, at least double the margins reported by insurers in the individual/non-group market ($745), the fully insured group/employer market ($689), and the Medicaid managed care market ($768).

    Purging customers: The Affordable Care Act makes it illegal for insurers to refuse to sell coverage to people with pre-existing conditions or to charge them more based on their health, but it doesn’t stop them from making premiums unaffordable. Insurers learned long ago that a way to drive away unprofitable individual and small-business customers is to jack up the rates so high those customers will leave. This is known as purging in the health-insurance business. Cigna and other insurers are planning double-digit premium increases for many of those customers in 2024 to boost profits. Cigna’s chief financial officer told investors last month that, “We are likely to have fewer customers in the individual exchange business in 2024 relative to where we are in 2023.” Getting rid of some of those people, he said, should increase the company’s profit margin.

    Aggressive use of prior authorization: Federal investigators found in July that some of the big insurers make much more aggressive use of prior authorization in Medicare Advantage and Medicaid than in their commercial health plans, meaning they are refusing to cover the cost of care for many seniors and low-income Americans to boost profits. Doctors have complained for years that insurers are increasingly refusing to pay for care their patients need, regardless of plan type. In the face of congressional scrutiny, Cigna, UnitedHealth and some other companies recently announced they will reduce the number of treatments requiring advanced approval, but don’t be surprised if that applies to a small percentage of patients — and primarily patients receiving care from doctors they employ or who work in clinics and other facilities the insurers own.

    Benefit buydowns: An age-old trick insurers have used for decades to improve profit margins is to reduce the value of their health benefit plans while they also increase premiums. Behind closed doors, this is called “benefit buydown.” It manifests in many ways, including making health-plan enrollees pay more out of their own pockets before the coverage kicks in, removing doctors and hospitals from their provider networks, increasing prior-authorization requirements, and refusing to pay claims after medical care has been provided. Cigna reportedly used a software program to reject more than 300,000 requests for payment over two months in 2022. Lawyers in California have filed a class-action lawsuit against the company, claiming it uses an algorithm to deny claims en masse and without human review.

    Increase in inter-company eliminations: The ACA requires insurers to pay 80-85% of revenues on patient care. If they spend less than that, they have to send rebate checks to their customers. But the big companies that have moved swiftly into health care delivery have found they can circumvent that requirement — and congressional intent — by paying themselves. The ACA requirement doesn’t apply to health care providers, so UnitedHealth, Cigna and CVS/Aetna in particular are steering their health-plan enrollees to care delivery entities they own. UnitedHealth, which employs more than 70,000 doctors, is clearly the pack leader. During the first half of this year, UnitedHealth categorized $66 billion as “eliminations.” That amounted to 25% of total revenues.

    Bottom line: Expect to pay more for your health insurance AND your health care next year — if you can get it at all — to make Wall Street financial analysts and investors (including those in the C-Suite) a little happier and richer.

    This article was originally published on Substack, HEALTH CARE un-covered.

    Here’s more from Just Care:

  • What happens when a Medicare Advantage plan endangers people’s health?

    What happens when a Medicare Advantage plan endangers people’s health?

    Medicare Advantage plans delay and deny care inappropriately, putting their members’ health at risk. Enrollees with serious medical conditions can find themselves unable to get critical care. As a general rule, the government does nothing to stop the wrongful delays and denials of care or to protect people in Medicare Advantage plans that are failing to cover their enrollees’ medically necessary care. Before signing up for a Medicare Advantage plan or deciding to remain in one, consider the consequences if you take a big fall or are diagnosed with a serious health condition.

    Twice now, the HHS Office of the Inspector General has found widespread and persistent delays and denials of care and coverage in Medicare Advantage plans. But, the government never names names. Similarly, the American Hospital Association has reported that some Medicare Advantage patients are not able to get essential hospital care. “Inappropriate denials for prior authorization and coverage of medically necessary services are a pervasive problem among certain plans in the MA program. This results in delays in care, wasteful and potentially dangerous utilization of fail-first requirements for imaging and therapies, and other direct patient harms.”

    The Centers for Medicare and Medicaid Services (CMS), the government agency that oversees Medicare, tells people that MA plans “must” cover the same services as Traditional Medicare, but there’s a profound difference between theory and practice. Despite reports of bad acts by insurers offering MA, CMS does not have the resources to monitor the Medicare Advantage plans adequately. Even when the OIG identifies bad actors, CMS appears to lack the political will to name the bad actors, let alone punish the bad actors appropriately.

    Moreover, some MA plans are failing to pay hospitals and other providers adequately, denying 18 percent of their claims inappropriately, according to the OIG. People enrolled in these Medicare Advantage plans are at risk of losing access to their local hospitals, which cannot afford continuing contracts with Medicare Advantage plans that don’t pay their bills.

    On rare occasions, CMS will temporarily freeze enrollment in some Medicare Advantage plans as a penalty for their bad acts. But, when it does, CMS does not alert members to the inappropriate denials. Moreover, it has no way to prevent these Medicare Advantage plans from continuing to delay and deny care inappropriately.

    Worse still, even when cautioned about bad actor Medicare Advantage plans—for example, by a local hospital—enrollees have little recourse. They generally cannot enroll in Traditional Medicare because, as a rule, they have no ability to buy supplemental coverage to fill coverage gaps. When they can get supplemental coverage, they often can’t afford it.

    Here’s what must happen to protect people with Medicare enrolled in, or thinking of enrolling in, a Medicare Advantage plan:

    1. The government, insurance sales agents, and all Medicare Advantage marketing materials must warn people with Medicare that they may be enrolling in a Medicare Advantage plan with high rates of coverage denials and high delay rates, jeopardizing their access to care. They must disclose denial rates and delay rates for each Medicare Advantage plan.
    2. The government, insurance sales agents, and all Medicare Advantage marketing materials must warn people with Medicare that they may be enrolling in a Medicare Advantage plan with high rates of payment denials, jeopardizing their access to care. It must disclose payment denial rates for each Medicare Advantage plan.
    3. The government, insurance sales agents, and all Medicare Advantage marketing materials should make clear that the government has no way to ensure that people enrolling in a Medicare Advantage plan will get the same benefits they get in Traditional Medicare and remove any language or suggestion to the contrary. The issue is not whether Medicare Advantage plans “must” cover the same benefits as Traditional Medicare, but whether they are doing so.
    4. The government must conduct annual audits of all Medicare Advantage plans and publicly identify all of them that have coverage and care denial rates of 10 percent or higher.
    5. The government must publish on its web site and send notices to people enrolled in any Medicare Advantage plan that has a 10 percent or greater denial rate.
    6. The government must give people a meaningful option to enroll in Traditional Medicare, with a limit on financial liability no higher than the lowest limit available in a Medicare Advantage plan; the cap should cost the government $10 less per person than the government spends on enrollees in Medicare Advantage. Right now, CMS must provide a Traditional Medicare option through its Innovation Center that caps out-of-pocket costs in Traditional Medicare no higher than the lowest level set by a Medicare Advantage plan.
    7. The government must establish a set of automatic escalating penalties to impose on Medicare Advantage plans that violate their contractual obligations, either through a ten percent denial rate or higher.
    8. To ensure the financial stability of hospitals, CMS should pay hospitals for MA enrollees directly whenever an MA plan has a payment denial rate above 10 percent and deduct hospital expenses from the MA plans’ capitated rate.

    In addition, the government should make clear in all its materials the annual maximum out-of-pocket costs in Medicare Advantage plans and advise people to check the maximum in any Medicare Advantage plan they are enrolling in. It should require Medicare Advantage plans to include this information prominently in all marketing materials. Sales agents should be required to disclose this information as well.

    As the American Hospital Association has said, “strong, decisive and immediate enforcement action is needed to protect sick and elderly patients, the providers who care for them and American taxpayers who pay MA plans more to administer Medicare benefits to MA enrollees than they do to the Traditional Medicare program . . . . In the recent contract year 2024 Medicare Advantage Rule, CMS noted that a number of the established regulations were already requirements under the health plan terms of participation in the MA program. Given MAOs historic lack of adherence to these rules, Congress should establish stronger programs to hold plans accountable for non-adherence. Additional requirements are insufficient without enforcement action and penalties to support compliance.”

    For too long, our federal government has allowed insurance corporations to mislead the public about Medicare Advantage, without revealing that all Medicare Advantage plans are different and that some are engaged in widespread and persistent delays and denials of care and coverage. Our federal government has failed to protect people from these bad actor insurers. These corporate insurers have endangered the lives of tens of thousands of people, to date. Their bad practices must end before the corporate insurers endanger the health and well-being of tens of thousands more older and disabled Americans.

    Here’s more from Just Care:

  • Hospitals dropping Medicare Advantage because of concerns with patient care

    Hospitals dropping Medicare Advantage because of concerns with patient care

    St. Charles Health System, a large hospital system in central Oregon likely will not continue to participate in Medicare Advantage, reports KTVZ.com. The hospital system’s leaders are concerned about patient care in Medicare Advantage. People with Medicare who want to know they have access to the best hospitals, including access to cancer centers of excellence, should switch to traditional Medicare.

    St. Charles is not alone; many hospital systems are not taking Medicare Advantage enrollees. St. Charles’ CEO says that the hospital system has considered dropping Medicare Advantage plans for some time because of mounting concerns. He reports that his hospital system is not alone. Hospital systems throughout the country are concerned about patient care in Medicare Advantage. The Mayo Clinic stopped taking Medicare Advantage enrollees at some sites last year.

    In the CEO’s words: “The reality of Medicare Advantage in Central Oregon is that it just hasn’t lived up to the promise. A program intended to promote seamless and higher-quality care has instead become a fragmented patchwork of administrative delays, denials, and frustrations. The sicker you are, the more hurdles you and your care teams face. Our insurance partners need to do better, especially when nurses, physicians and other caregivers are reporting high levels of burnout and job dissatisfaction.”

    The American Hospital Association (AHA), the trade association for most hospitals reports that it “is increasingly concerned about certain (Medicare Advantage) plan policies that restrict or delay patient access to care, which also add cost and burden to the health care system.” To make matters worse, it appears that some Medicare Advantage plans are engaged in fraud as well as inappropriate delays and denials of care and coverage.

    St. Charles hospital executives see higher rates of denials of care in Medicare Advantage and long arduous processes for getting Medicare Advantage plans to approve medically necessary care. St. Charles health system is considering whether it will renew Medicare Advantage contracts with PacificSource, Humana, HealthNet and WellCare.

    The bottom line: With traditional Medicare, your treating physicians call the shots, deciding what care is medically reasonable and necessary, and Medicare covers that care, without second-guessing and coming between you and your doctors. With Medicare Advantage, many insurance companies second guess treating physicians and deny care or delay care, endangering patient health.

    The Office of the Inspector General has reported widespread and persistent inappropriate delays and denials of care and coverage in Medicare Advantage. But, the Centers for Medicare and Medicaid Services (CMS) has so far refused to identify the bad actors or sanction them appropriately, putting older adults and people with disabilities at serious risk.

    Healthy patients in Medicare Advantage should be fine. But, even if you are healthy today, you could need complex care tomorrow and your insurance should cover that care. That’s why we have health insurance. In some Medicare Advantage plans, you might not get needed care in a timely manner, if at all, regardless of whether you need it.

    Here’s more from Just Care:

  • Be a Hero tells Congress to end Medicare Advantage wrongful delays and denials of care

    Be a Hero tells Congress to end Medicare Advantage wrongful delays and denials of care

    Corporate health insurers must stop taking advantage of people in Medicare Advantage plans, denying and delaying their care inappropriately, often to the detriment of their health. Corporate health insurers also must stop gouging Medicare and taxpayers through tens of billions in overcharges, driving up Part B premiums for everyone with Medicare. Here’s what Be a Hero , a not-for-profit organization fighting for a more just health care system in the United States. has to say:

    Health insurance corporations are gouging Medicare, taxpayers, older adults and people with disabilities by tens of billions of dollars each year, while wrongly delaying and denying the care people need, with impunity. 

    While some people on Medicare Advantage are currently satisfied with their plans, when they become ill, they face serious risks of inadequate care.  The failure of Medicare Advantage to live up to its promise is placing the very integrity of Medicare in jeopardy. 

    Neither federal law and regulations, nor the Centers for Medicare and Medicaid Services (CMS) are doing enough to protect older adults and people with disabilities from Medicare Advantage bad actors and to ensure that federal dollars spent on Medicare Advantage are put to good use. 

    We believe that Congress has a responsibility to protect the rights of, and advance health equity for, everyone with Medicare—including older adults and people with disabilities on Medicare Advantage plans. 

    The Problem

    • Health insurance corporations are denying care they are supposed to cover in Medicare Advantage and putting older adults and people with disabilities in harm’s way

    The Health & Human Services Office of the Inspector General has twice reported that  health insurance corporations are engaged in widespread and persistent care denials in some Medicare Advantage plans. These delays and denials lead to outsized profits for insurers, but they lead to serious harm for older adults and people with disabilities.

    • Health insurance corporations are gouging the federal government and taxpayers

    Insurance corporations are illegally overcharging the government as much as $73 billion this year alone and people on Traditional Medicare and taxpayers are footing the bill. This insatiable profit seeking is eroding the Medicare Trust Fund and driving up costs for people in Traditional Medicare, who will pay $145 billion extra in Part B premiums over the next 8 years to subsidize Medicare Advantage.

    • Health insurance corporations are not being held accountable for their bad acts in Medicare Advantage.

    The Centers for Medicare & Medicaid Services rarely if ever penalizes insurance companies that inappropriately delay and deny care and endanger the lives of their enrollees, let alone cancel their contracts. 

    What Congress Can Do About It

    • Ensure older adults and people with disabilities can access the care they need.

    Congress should take action to combat rampant and wrongful delays and denials of care by requiring the Centers for Medicare & Medicaid Services to force corporate health insurers to comply with Medicare’s standards. But, perhaps the most important thing Congress could do, is to give people a meaningful choice of quality health care they can rely on by strengthening Traditional Medicare with an out-of-pocket cap and by adding dental, vision and hearing benefits.

    • Stop corporate health insurers from scamming the government and profiteering at patients’ expense. 

    Congress should take action to change the payment system that allows corporate health insurers to profit off making their patients look sicker than they actually are. The current system also incentivizes insurers to offer low quality provider networks and to delay and deny care—making it hard for people to get the care they need. 

    • Hold the bad actors accountable. 

    The rampant, inappropriate delays and denials will never fully come to an end without real accountability. Congress should require the Centers for Medicare & Medicaid Services to complete rigorous annual monitoring of compliance across the plans of the top 15 Medicare Advantage insurers (who together are responsible for the lion’s share of enrollees) and provide them with the resources to do so, implement a series of automatic, escalating penalties on plans and insurers that fail to comply with contractual obligations and require automatic cancellation of contracts or barring of offending insurance corporations from the Medicare Advantage market in the face of persistent compliance failures.

    For More Information

    This fact sheet was prepared by Be A Hero & Just Care USA. If you’d like to learn more email us at [email protected].

     

  • Cigna sued in California for denying coverage 300,000 times in two months

    Cigna sued in California for denying coverage 300,000 times in two months

    Corporate health insurers’ use of AI to deny coverage is too often killing and disabling people. People in Medicare Advantage, people in State health insurance exchanges and people with job-based coverage are all at risk.  Now, Axios reports that a class of people are suing Cigna for using computer software to “deny payments in batches of hundreds or thousands at a time.” Why not? It maximizes Cigna’s profits, and Cigna has so far been able to get away with it.

    Mounting evidence shows that corporate insurers offering Medicare Advantage plans too often deny costly and critical care, including nursing home stays, rehab, home care and hospital care. This is care they are paid to cover and that traditional Medicare covers.

    The Clarkson law firm filed the lawsuit in California claiming that Cigna is violating state law. Cigna is supposed to thoroughly and fairly review insurance claims under California law. Computer algorithms is clearly at odds with that requirement. It’s hard to believe that a judge could find that a speedy computer review of a claim could be fair and thorough. But, these days, anything’s possible.

    The lawsuit claims that Cigna’s AI system denied 300,000 requests for authorization over two months in 2022. The system spent an average of 1.2 seconds on each claim. Thorough? Fair? One Cigna medical director, Cheryl Dopke, denied 60,000 claims in one month. Thorough? Fair? Hardly. California law requires individual review. And four out of five claims that were reviewed were overturned on appeal.

    Use of AI is the latest way health insurance corporations can inexpensively and swiftly turn a huge profit. Who’s designing the computer software algorithms? What’s their goal? As many denials as possible is what’s in Cigna’s economic interest. You have to wonder what questions Cigna asks about the algorithms before buying the software.

    Even some Republicans in Congress appear concerned, including House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-Wash.). She wrote Cigna for an explanation. Members of Congress appear to appreciate that people in Medicare Advantage and Medicaid are at risk of wrongful denials. But, what is she and her fellow members of Congress willing to do about it?

    Here’s more from Just Care:

  • Office of Inspector General finds insurers inappropriately deny care to people with Medicaid

    Office of Inspector General finds insurers inappropriately deny care to people with Medicaid

    Healthcare Finance reports on new Office of Inspector General findings regarding high prior authorization denial rates in Medicaid managed care as well as a high likelihood that some people with Medicaid are not getting the care they need. The OIG urges the Centers for Medicare and Medicaid Services (CMS) to do more to ensure that the insurance companies offering managed care to people with Medicaid are honoring their obligations to cover needed care, rather than putting profits first by denying care inappropriately.

    The Office of the Inspector General is concerned that people with Medicaid are not getting needed care that corporate insurers should be covering. Moreover, there is little oversight of these corporate insurers. The Centers for Medicare and Medicaid Services and state insurance departments only conduct limited oversight of the insurance companies’ denials. And, people with Medicaid have restricted access to reviews of their denials. Even in Medicare Advantage, CMS oversight is extremely limited; CMS allows health insurers to deny care wrongly with near impunity.

    Medicaid insurance companies denied about 12 percent of prior authorization requests or about one in eight of them on average. But, ten percent of the managed care plans that the OIG reviewed denied one in four or more requests for prior authorization. People with Medicaid should know which plans have these high denial rates so they can avoid enrolling in them.

    The OIG fears that oversight bodies are not on top of many inappropriate denials of care. So, inappropriate denials continue because they are not addressed.

    In addition, the Medicaid appeals process in most states does not offer people the opportunity for an independent review of denials. So, the appeals process is not a check on most insurance companies offering Medicaid. People do have the right to fair hearings in their state, but the process can be challenging for people with Medicaid. Appealing to the Medicaid health plan directly is also not common.

    The OIG claims that the system is better for people in Medicare plans operated by insurance companies. That may be true, but the differences do not lead to particularly good outcomes for people with Medicare in these corporate managed care plans. The Centers for Medicare and Medicaid Services does little to hold Medicare Advantage plans accountable for their bad acts, even if these plans must report data on denials and appeals.

    If CMS reviews the appropriateness of Medicare Advantage prior authorization denials each year, it should report its findings. People should not be forced to choose a Medicare Advantage plan without knowing the risks that they will be denied care inappropriately if they enroll.

    Prior authorizations can be harmful to people’s health, often delaying critical care needlessly. More than nine in ten physicians report these delays. And one in three physicians say that prior authorization leads to serious harm to patients they care for. Nine percent of them say prior authorization leads to “permanent bodily damage, disability or death.”

    Here’s more from Just Care:

  • Corporate health insurers use NaviHealth algorithms to deny care in Medicare Advantage plans

    Corporate health insurers use NaviHealth algorithms to deny care in Medicare Advantage plans

    Beware of corporate health insurers that use NaviHealth, an AI system tha can inappropriately deny care to people in Medicare Advantage plans. Former employees at NaviHealth report that its AI algorithms wrongly deny care to Medicare Advantage enrollees in serious health, reports Stat News. UnitedHealth, which owns NaviHealth, and other health insurance companies, rely on NaviHealth in their medical decisionmaking,

    Employees at NaviHealth are complaining in internal communications that insurers are denying care to people who are on IVs in rehab facilities. Medicare should cover up to 100 days in a rehab facility for eligible individuals. But, NaviHealth sometimes determines that they need to leave rehab before it is appropriate for them to do so.

    As Stat previously reported, insurance corporations use AI–computer programs–to deny care to Medicare Advantage enrollees with serious diseases and injuries. The NaviHealth system does not consider individual patient’s needs in its determinations about when to stop covering care. Patients, physicians and NaviHealth workers are “increasingly distressed” that patients are not able to get the care they need as a result of these computer algorithms.

    Former medical review employees at NaviHealth say that they were not allowed to use their independent clinical judgment to allow continued stays in rehab facilities when the NaviHealth system said to deny care; they had to follow the algorithms. “That was very different from before we were owned by Optum.”

    As Stat News reports, this is the dark side of AI. Reporters spoke with five former NaviHealth employees, patients, lawyers, experts; they also reviewed internal communications at NaviHealth. For its part, NaviHealth says its algorithms are merely a guide and NaviHealth does not make coverage decisions. But, how often do insurance company medical review staff not follow the NaviHealth “guide” when the medical evidence suggests patients still need care?

    Stat News finds that the NaviHealth algorithms are central to coverage decisions, influencing outcomes. NaviHealth likely is responsible for huge profits for UnitedHealth and other health insurance corporations. But, those profits come at the cost of people’s health and sometimes endanger their lives. Patients’ only resort when NaviHealth denies care is to pay privately for the health care services and appeal the denials. (And, that’s only if they have the means to do so.) Patients have a high likelihood of prevailing, but many of them cannot afford to pay for that care privately.

    Here’s more from Just Care:

  • Does your Medicare Advantage plan deny care frequently? Who knows

    Does your Medicare Advantage plan deny care frequently? Who knows

    Robins Fields reports for Pro Publica on the serious challenge facing anyone, including people with Medicare, trying to choose health insurance. There is no way for them to know which corporate health plans deny care frequently; some of these health plans have super high denial rates that can put the health and well-being of their enrollees at risk. So, if you’re choosing among Medicare Advantage plans, the corporate health plan alternative to the government-administered traditional Medicare option–which has a very low denial rate– beware.

    As Fields explains in her story, people need to know about health plan denial rates in order to make an informed choice. After all, you’re buying insurance to ensure that when you need care, you can get it and, when you need care urgently, you can get it swiftly, without worry about the cost. But, even though reports show that some health plans deny as many as one in three requests for coverage, jeopardizing access to care for people in those plans, you can’t know which ones those are.

    The problem of not knowing about Medicare Advantage plan denial rates is most acute when you are diagnosed with a complex and costly condition and need a lot of care. Will you get to the oncologist before your cancer spreads? Will your health plan even cover the tests you need to see whether you have cancer?

    Fields tried to get the information on health plan denial rates without any success.  What’s so troubling is that this information should be easily accessible but neither the federal government nor state governments have tried to correct it. Pro Publica has already exposed how top insurers deny claims speedily and even in bulk in some cases. So, it’s clear that people need protection from these insurers.

    Of note, the Affordable Care Act legislation gives federal regulators authority to force insurers to turn over health plan denial information. But, more than ten years later the federal government has not collected helpful information.

    Fields reports that only two states collect some health insurer denial rates for public scrutiny. Unfortunately, they don’t collect data on most health plans.

    As Karen Pollitz, a researcher at Kaiser Family Foundation reports, “This is life and death for people: If your insurance won’t cover the care you need, you could die.” “It’s all knowable. It’s known to the insurers, but it is not known to us.. . . The insurers are not wanting to disclose this information and push back when asked for it. They claim it imposes burdens that “outweigh the benefits for consumers.”

  • Congress sits on its hands while Medicare Advantage insurers gouge taxpayers and enrollees

    Congress sits on its hands while Medicare Advantage insurers gouge taxpayers and enrollees

    The Medicare Advantage program, Medicare Part C, which allows corporate health insurers to contract with the government to offer Medicare benefits, was born with the assumption that it could save Medicare money. Instead, a new report out of the mainstream USC Schaeffer Center for Health Policy and Economics estimates that Medicare Advantage plans are costing taxpayers and people with Medicare an additional $75 billion in overpayments this year alone. The report only confirms findings by University of California at San Diego professor, Richard Kronick, of massive government overpayments to Medicare Advantage, but Congress sits on its hands.

    Republicans in Congress don’t seem to care about eliminating all the waste in Medicare Advantage. It’s the health insurers offering Medicare Advantage plans that will help fund their 2024 reelection campaigns. And, that’s not something they want to jeopardize. Many Democrats in Congress also appear to live in fear of losing support from the corporate health insurers and are doing little to address the massive overpayments, as they should.

    How do these Medicare Advantage overpayments happen? Medicare Advantage overpayments happen for a variety of reasons, but the largest reason is that people enrolled in Medicare Advantage are considerably healthier than people in traditional Medicare.  Because of a defective payment system, the government pays Medicare Advantage plans as if their enrollees are sicker than people in traditional Medicare. The high proportion of people who are healthy in Medicare Advantage cost these Medicare Advantage plans on average less than $1,000 a year as compared to the more than $12,000 a year the government typically pays Medicare Advantage plans to care for them.

    MedPac, the agency overseeing these government payments, has calculated the overpayments at $27 billion this year because the Medicare Advantage plans assign multiple diagnosis codes to their enrollees in order to boost their earning and often get quality bonus payments as well. But, MedPac has not factored into its calculations the $50 billion or so a year in Medicare Advantage overpayments resulting from the Medicare Advantage population being so much healthier than the traditional Medicare population.

    The researchers at USC appreciate that the Medicare payment system for Medicare Advantage plans is defective and needs an overhaul. Paying the insurers offering Medicare Advantage plans as the government currently does leads to massive overpayments. The researchers, however, do not speak to the fact that the defective payment system–upfront payments unrelated to the cost of services delivered– also leads to massive inappropriate delays and denials of care to people. People with cancer, heart disease, stroke and other costly and complex conditions are most at risk–and that’s most of us, if not now, down the road.

    The USC researchers like the idea of competitive bidding among MA plans as an alternative to the current payment system, which I hear is a nonstarter from the MA plans’ perspective. That shouldn’t matter, but it does. Regardless, competitive bidding doesn’t address the need to ensure that the payment system stops creating a disincentive for the Medicare Advantage plans to withhold care from the people who most need it–the 10 percent of people with Medicare with the costliest conditions.

    The government’s payment system will be right only if and when the Medicare Advantage plans are promoting their high value care for people with cancer, heart disease and stroke. Until then, consider enrolling in traditional Medicare if you can. If you enroll in Medicare Advantage, beware the Medicare Advantage plans engaged in widespread delays and denials of care. The administration is not naming them for the most part. And sometimes, it is giving them four and five-star ratings.

    Here’s more from Just Care: